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Home and Community Based Settings Transition Project Advisory Taskforce Meeting

March 10, 2015

Welcome and Introductions: Lisa DiMartino, Adrienne Mallinson, Ryan Donnelly, Cynthia

Gaudreault, Carol Stamatakis (for David Ouellette), Christine Selmer, Jan Skoby (for John

Fenley), Susan Lombard, Kaarla Weston, Dan Klein

Advisory Taskforce Overview:

Transition Plan Overview:

Using an overhead and handouts Dan completed a Transition Plan Overview,

focusing on the aspects of high level transition plan:

1. Inventory

2. Assessment

3. Remediation and Compliance

4. Outreach and Transparency

5. Public Comment: Draft Comprehensive Transition Plan

Dan highlighted timeframes that are relevant to this group’s responsibilities.

Question Who is Transition Framework Team?

Answer It is a collaborative effort with DHHS and IOD. Question How will group get summaries of meetings? Alternates need to be

made aware.

Answer We will be using an electronic system. There is additional work to be done to ensure everyone has access to information.

Settings Requirement/Person-Centered Planning/Conflict Free Case Management:

Dan provided brief information relative to the new settings requirements: reviewed

expectations by CMS. Emphasized: Autonomy and Independence, choices

Each seat of advisory Taskforce has a delegate, a role to play back to respective

communities, please bring back feedback and points of clarification from your

respective communities.

Home and Community Based Settings Transition Project Advisory Taskforce Meeting - Minutes March 10, 2015

CMS has accepted other plans from other states. NH will be reviewing approved

plans and potentially adopting aspects of their plans. NH has discussed plans with

other states.

Susan Lombard updated on conflict free Case Management.

Kaarla provided a brief update on person centered planning.

Dan explained: The final rule has 3 requirements involving PCP, Conflict Free Case

Management and the Settings Requirement. There are three separate parallel

processes. We are focused on the “Settings Requirements.” This group is

responsible for one of the three requirements in which the state has five years (4

remaining) to be in compliance.

A request was made to provide the link to website. This will be provided in a central location,

which is currently being researched. Minutes to meetings will also be posted in that same

manner.

A request was made to provide the members of the group with a spreadsheet containing the

names of all sites- for settings.

Assessment Process:

Dan provided a summary of the High Level and Timeframes for input to the process.

A copy of the provider assessment tool developed by Georgia was distributed to the

group. Members were asked to review this and highlight areas that do not fit NH, as

well as areas felt to be useful to be included in the New Hampshire assessment tool.

The transition team will be doing the same review of the Georgia plan.

Once we complete a Provider Assessment for New Hampshire, we will pilot it with a

small number of providers, to determine the best questions. In April we will submit

our draft provider assessment tool. Based on their response we may need to modify

the assessment.

Question Is this a separate mechanism for providers and individuals? Answer There are two tools submitted to CMS. Georgia has a provider tool

and a separate tool for individuals.


Next Steps:

We will start with a provider assessment and then work on a consumer assessment

next.

After this group completes the review of the assessments, the next step will be to

spend time on remediation efforts.

We will be looking at separate waivers, starting with CFI, first.

The original plan for the Advisory Taskforce was for it to have 17 seats. This was

expanded as a result of public comment. Feedback from stakeholders assisted this

process.

During the assessment process, the team will also be looking for feedback from the

Taskforce on data collected and the sample validation plan. An independent entity

will validate provider assessment. A summary of the results will be compiled and

distributed to this group for feedback.

A narrative white paper based on assessments will summarize comprehensive

transition plan to bring us in compliance. This group has a significant role in that

plan.

The Taskforce will also be consulted for policy development – about a year from this

time – including ongoing monitoring and compliance, as we need to provide CMS

assurances that changes are being monitored and will continue.

This Advisory Taskforce will be consulted continually, and at regular intervals the

transition team will consult with this group will for feedback.

The Advisory Taskforce is specifically comprised of individuals representing all the

different affected areas. The expectation is that the individual holding the seat

representing a particular group will continually touch base with others for

comments and input. The representative will then bring those comments back to the

Taskforce for inclusion in discussions and conversation.


The final transition plan will be submitted to CMS in approximately one year. The

state of New Hampshire has roughly 3 years after that to establish compliance upon

completion of final transition plan. CMS will give us feedback.

The group was provided with the states response to questions presented at the

public comment sessions and was given a few minutes to review the responses and

ask questions.

Other/Questions:

Question Comment regarding DSP seat on the Taskforce – Will David Ouellette be doing double duty?

Answer Yes, that was the expectation.

Question Since DSP is such an important role; would it be possible for the Taskforce to convene a panel of DSPs at some point? Perhaps pull together a group so that there would be two-way communication with a constituency.

Answer Individual groups can develop advisory councils, to provide input and discuss. Any of these groups are always welcome to invite members of this Taskforce to attend their meetings.

Question There is currently one person in attendance at this meeting with a

disability. Will those invited to be part of this Taskforce be provided with support?

Answer Yes, we will reimburse for transportation, a support person, or for respite. Sue Orr is the contact person for reimbursement for this.

Question There is a concern from many of the sites regarding locked doors on

bedrooms, food availability, and keys to doors. This is a concern for some of our smaller settings. Will this group get into that level of detail?

Answer Yes, we will dive into the remediation or respond to requirement, health/safety.


Question CMS expectations, is there an opportunity for CMS to provide clarification to this group?

Answer We discussed the benefits pros and cons of entire group discussing with CMS. DHHS will seek technical assistance from CMS as needed on an ongoing basis when presented with specific questions that require clarification.

Question A question was posed regarding the response to comment number 25,

regarding nursing home properties and adult day. Need more info.

Answer Susan shared that we will want to look carefully on how that is addressed. The response to that question is brief because we need more tangible data to be informed about how to address the remediation issue.

Question Which settings will be under the waiver?

Answer HCBC funding will need to be flushed out for the adult day. Re: 521

and 525, concern about isolation was raised and not having access to the community. We want to make sure we do not ignore the day programs for individuals in all 4 waivers.

Meetings are scheduled regularly for the 2nd Wednesday of the month. Next meeting

will be April 8th at the IOD Professional Development Center.

The official website for the waiver transition program, where all the documents and

information can be found, is: http://www.dhhs.nh.gov/ombp/Medicaid/draft-

transition-framework.htm

http://www.dhhs.nh.gov/ombp/Medicaid/draft-transition-framework.htm


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April 8, 2015

Welcome and Introductions: Darlene Cray, Cynthia Gaudreault, Mary Beth Smaha, Chris

Selmer, John Fenley, David Ouellette, Lisa DiMartino, Adrienne Mallinson, John Richards,

Ryan Donnelly, Cheryl Steinberg, Deb Fournier, Kaarla Weston, Dan Klein, Mary

Maggioncalda, Linda Bimbo, Susan Orr

Advisory Taskforce Overview:

Transition Plan Overview

o CMS released the final rule last year. States have been given 5 years to

complete this process.

o A brief review of the new settings requirements was provided, using the slide

deck, which will be uploaded to Box.

o We have been learning from other states (particularly Georgia) with regard

to the process they used, as well as feedback from CMS. This information has

been very useful in our process. Also used their assessment tools to help

drive the development of NH’s.

Provider Assessment Review

The draft of the Provider Assessment was given to the group for review and input.

NH specific document utilized questions from eight other states and customized the

tool for NH.

CMS does not expect that everyone is in compliance today. The task is to evaluate

and ensure that the compliance process is begun and completed in the 5 year span.

This is a multi-step process. Ideally, participants will contribute to this process

now; and later with a participant assessment.

This will be analyzed and converted into a report that will eventually drive the

compliance process.

Questions, comments, and concerns were received. (see below)

This is not final yet. A copy of the next draft will be sent to the Taskforce. We will

run a pilot of this with a small group of providers, receiving more input, before the

final goes out to all providers.

Home and Community Based Settings Transition Project Advisory Taskforce Meeting - Minutes April 8, 2015

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Participant Assessment

We will be developing an assessment for participants that will be used across all

three waivers.

There is a lot of information that has already been garnered through the National

Core Indicator survey, and this information will be used.

No one will be required to participate. We will make it as user friendly as possible.

Georgia used the case manager to assist in completing the assessment.

There is no requirement for anyone to complete this; although the information will

be invaluable in this process.

Comments/Recommendations/Questions:

o Some people will need assistance in completing this, and we want to make

sure that the assistant does not influence the answers.

o People who administer the participant survey need to be completely

independent and neutral, and can do it using people first language.

o For NCI, the proxies for individuals who are non-verbal are usually the

guardians.

o It was suggested that we reach out to the advocacy groups for each area to

provide the proxy service to complete the participant survey.

o Very few people would have access to a computer, so we would have to do

this via a paper survey.

o The list of individuals who receive waiver services is available via the State.

o People feel comfortable with their case managers and their living location,

and the survey should be conducted in that setting.

o It was suggested that ServiceLink could be a good location and/or actually

assist with completing the assessment for CFI participants.

o Service coordinators can assist with individuals served under the DD and

ABD waivers. Case managers for the CFI waivers.

o Training for service coordinators and case managers should be provided

regarding assisting with completing the assessment.

o Choice of setting

DRC said questions not reflective of nondisabled settings

Hypothetical vs. the reality.

o Example, four-person home, staffed. Can’t go to church because no staff.

o Define response areas

Home and Community Based Settings Transition Project Advisory Taskforce Meeting - Minutes April 8, 2015

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We would like to convene a smaller group – one representative from each area – to

develop the first draft of the participant assessment. The first draft needs to be

completed by the May Taskforce meeting. (John R., Mary Beth, Darlene)

We will send out samples from other states. There is also a website, where people

from other states are compiling resources of what they are doing. We will send that

link to the group. (hcbsadvocacy.org) select State resources. This site includes

questions from other states, with the answers from CMS.

Other Business:

Toolkit is being compiled for this group. Instructions will be sent to group

regarding Box, which is a place dedicated to this Taskforce, and will contain all the

documents and information needed for this group.

The official website for the waiver transition program, where all the documents and

information can be found, is: http://www.dhhs.nh.gov/ombp/Medicaid/draft-transition-

framework.htm




May 13, 2015 NH Hospital Association, 125 Airport Rd., Concord, NH

Present: Ryan Donnelly, Mary Beth Smaha, Lisa DiMartino, Elizabeth Kenney, John Richards, Cynthia Goodreault, Darlene Cray, Mary Maggioncalda, Adrienne Mallinson, Jan Skoby, Kaarla Weston, Eric Johnson, Cynthia Mahar, Cheryl Steinberg, Kristen Schmidt.

HCBS Provider Self-Assessment

• Edits based on Taskforce feedback o Just received DRC comments and will review/incorporate the recommendations into

the final version. Not currently in the version that was distributed to the group. o The group reviewed the Provider Self-Assessment. There were no additional

changes. • Pilot update

o Received about 8 respondents. Several changes were suggested. o Pilot participants advised that it would take an estimated 60-90 minutes to complete

the survey. We will include that in the instructions. • Next steps

o Hope to have this out by this Friday – next week at the latest. o Will track the responses to make sure we have responses from everyone. o Any residential or non-residential setting that is not in someone’s own home will

need to complete a self-assessment. For 521/525 combined only the day component is included in the self-assessment.

o A table of Eligible Sites has been developed to assist people in determining if they are exempt or not. (See below)

o Whether or not a setting is currently accepting Medicaid funding in NH or other states, we will still ask them to complete the survey.

o Surveys will be returned to the IOD, and no individual data will be distributed. Only aggregate data will be released.

o Most other states are doing this provider assessment, and this information is available on the website. (www.hcbsadvocacy.org)

Participant Survey

• Taskforce Sub-Group reviewed and assisted in developing the survey. • Advisory Taskforce participated in a review of the draft survey. Changes will be

incorporated, and will be sent to the group for another review before it gets distributed to participants.

• This will be able to be done on-line, on paper mailed or FAX’ed. • Participant names are optional, but site address is required.

Home and Community Based Settings Transition Project Advisory Taskforce Meeting May 13, 2015 Page 2 of 3

• These will be distributed to participants through service coordinators for DD and ABD and case managers for CFI.

• Need to give a longer time in order for this process to be completed. It’s a big time commitment for service coordinators and case managers. We will get input from the area agencies to see how long they think this will take to accomplish. Not every individual needs to be surveyed, just as many as we can get within the time period.

• A suggestion was made to provide some sort of incentive for completing this – a raffle of some sort of something like that.

• People First and other similar types of meetings could be a good way to get a larger group to complete this.

• The people who we can’t reach may be the ones from whom we really need to get input.

• A suggestion was asked if funding for Postage reimbursement for agencies and individuals will be provided.

Next steps

• After we receive input from service coordinators and case managers, we will update the survey and send to this group again for any further comments.

• Site visits will be conducted during the summer to measure the reliability of the information.

Other Business

• Next Meeting June 10 at IOD, Concord.

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Home and Community Based Services – Waiver Settings Transition Project

Advisory Taskforce Meeting June 10, 2015 – 10am to 12 noon

UNH Institute on Disability, 56 Old Suncook Rd. Suite 2, Concord, NH

Minutes

Rosemary Simino, Adrienne Mallinson, Steve Woods, Robyn Magarian, Ryan Donnelly, Chris Selmer, Cynthia Gaudrault, Cheryl Steinberg, John Fenley, John Richards, Heather Hannafin, Mary Maggioncalda, Kaarla Weston, Eric Johnson (CSNI)

Welcome – Kaarla Weston, BDS o Dan Klein is no longer working on this project. His work was focused on the

establishment of the Advisory Committee. We appreciate the work he did. o Linda is traveling but is still managing the project including surveys and

responses to inquiries while on the road.

Provider Self-Assessment update o Instruction and link were sent Lorene at BDS on 5/28/15. o The deadline from to return/complete the assessments was moved from 6/12 to

6/26. Since CMS has an expectation that any facility receiving Medicaid HCBS funding participate in this survey, the instructions stated that completion was mandatory; as a result we expect to have 100% participation. There was some reaction to the language of the request, but we will clarify the CMS requirement, including a more thorough explanation of the federal requirements when we send the reminder.

o The original instructions and expectation was that all responses were to be completed online. However, after requests for alternate means, FAX and mail responses are now permitted.

o We have been receiving many inquiries and questions. These have all been handled by Linda Bimbo. As a result of these questions, we will develop an FAQ to send along with the reminder.

o A table was provided to the group which reported the number of responses received so far.

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o There is a concern that private homes will be shut down if they can’t meet all the requirements.

Participant Survey – update o Instructions and link were sent to Case Managers and Service Coordinator

Supervisors on 6/1, with a requested due date of 6/30/15. There was a concern expressed that more time may be needed for folks to complete this.

o The question of how can we make sure we don’t miss people who are in temporary facilities was posed. We will work with Ombudsman’s office to ensure we provide the opportunity for everyone to participate.

o We are hoping to get as many people involved as can be. It’s not “mandatory,” but it’s essential to the process.

o A table was provided to the group which reported the number of responses

received so far.

Validation Process. Validation will be done on site and in person. Validation process must be completed by the end of August. A sampling of responses will be chosen – some will be random, but sites with notable issues will be selected so that problem areas can be addressed.

o There is general agreement that there needs to be a minimum of 2 people on each team.

o Training to ensure that each person understands CMS guidelines and the new requirements is essential. HSRI was noted as a possible entity to provide the training.

o Technology options will be explored to review the responses. o The existing self-assessment/survey tools will be used. The validation process

will build on the original answers and obtain more specific and detailed comments, in order to confirm that the answers initially provided are accurate.

o There is funding in the budget to perform this validation, and there are several options as to who will conduct this (see below).

Additional comments provided by Taskforce Members: o Should be done by an outside person – not an employee of the group home or a

DSP.


o It was suggested to have peers/advocates (e.g. person with a disability, etc.) as part of the validation team. Transportation may be an issue for this, but solutions will be considered.

o State of NJ is doing 100% sampling in their validation. o Teams could be located regionally. This way, they would be able to cover the

area more efficiently. o CSNI has already been doing surveys and their staff has been trained in interview

techniques. CSNI people don’t work for a specific agency, but most people at one time worked with DD and/or ABD individuals. They could be impartial, as long as they don’t work for the agency at which they are doing the validation. Eric Johnson will check on capacity of CSNI to see if this would be possible.

o It was expressed that utilizing CSNI folks for DD/ABD would be a conflict of interest. This could be resolved if the validation for CFI is conducted by CSNI and have LTC Ombudsman conduct validation for DD/ABD. Darlene Cray will be contacted regarding feasibility of the Ombudsman’s office doing a portion of the validation.

o It would be valuable for a member of the team be familiar with the agency (case manager?).

o DRC was suggested as a possibility to perform validation, but there is a concern with their capacity.

o There is some merit in looking at the option of utilizing UNH graduate students; however, the hope is to use folks who have experience in these areas.

o Day programs are a totally different category, and the folks who do the validation will need to be specially trained on this.

o Training. Each individual conducting the validation will need to have thorough knowledge of the program requirements including: HCBS Settings Rules, CMS intentions and how is that demonstrated in NH sites, etc. Additionally, it’s essential that everyone have extensive training on interviewing techniques.

We have lots of resources from CMS on training. HSRI has been providing training to DHHS staff on interviewing

techniques, as well as other area. Linda B. will contact them to obtain a list of their training opportunities.

o Data collection and input Teams will collect data onsite and enter into Qualtrics database for

analysis Will be sent to DHHS as summarized results. DHHS will then arrange for Data Analysis. The IOD has a staff member

with Medicaid analysis experience. This person will most likely be conducting the analysis and submit a report of the Provider Self-Assessment and Participant Survey, including results of Validation Site


Visits. Analysis of data will be done by Waiver and include identification of trends, strengths, and gaps.

Written report with summary of data, conclusions, recommendations – becomes ground work for development of NH Transition Plan

Other Comments: o CMS will be consulted through the process to address the data points that arise.

For example: Based on previous experience, it is understood that transportation is an issue with regard to many of the HCBS requirements. Since sites may need to address that in order to be in compliance, will CMS address and provide funding for transportation?

o A question was asked about site certification, and how can we get someone into compliance that is not.

o With regard to new programs: How do we make sure new programs are in compliance In the future? Kaarla responded that our regulations are in the process of being amended, and we will incorporate the new modifications to the regulations. This will be included in the Office of Program Support checklist. This process is already in place, and just needs to be modified. If, during the annual licensing survey, sites are not in compliance, they have a specified number of days to come into compliance.

o A question was asked: Will the results of the participant surveys be provided to the facility so they know what has been reported? Answer: Any such issues will probably be addressed during the validation process. There will be some sort of exit interview where the issues will be itemized.

o Clarification was requested on the extent of this group’s responsibility with regard to writing the Regulations. This group will not be writing the regulations for CFCM or PCP, but will be responsible for only the settings. There will not be a separate rule revision process for this taskforce.

o DHHS has enlisted attorneys to make sure we are in compliance with Conflict Free Case Management and Person Centered Planning, as well as CFI, DD, & ABD Waivers in terms of Conflict Free Case Management. We are expected to already be incompliance with these areas, and the attorneys are reviewing to see ensure that we are.


Advisory Taskforce Meeting July 8, 2015 – 10am to 12 noon


Minutes

Deb Fournier, Mary St. Jacques, Adrienne, Ryan, Kaarla, Cynthia Gaudreault, John Fenley, Heather Hannafin, John Richards, Linda Bimbo, Lisa DiMartino

Introduction of Mary St. Jacques

Provider Self-Assessment update o Received both via paper and electronically. Mary is entering the paper ones o Have received many phone calls from family, mostly on how to answer

questions. o Many people were afraid of losing funding; we have been assuring them that is

not the case. o Assuring folks that no information will be shared, info will be evaluated by UNH

and shared in aggregate. o Linda met with a provider who does some service provision, but mostly with

ABD, and had a helpful conversation on how to address the questions, and review questions included and not included in this review.

o Scope is very specific to services in NH that are funded by CMS that are not in people’s homes.

o Had hoped to be able to match up information on surveys with master list; however, we haven’t been able to be that specific. We will not be able to have an exact count by service type. This will not hurt analysis, but we will not have as specific data by waiver.

o Once all the information is entered and cleaned, we will forward to the evaluator to review.

Participant Survey – update o Received questions from folks concerned about anonymity. o So far, we have 443 surveys collected. o A request was made to case managers to help facilitate these surveys; many

were not able to do this. Time could be a factor. Many case managers do not work full-time, and it takes about an hour to complete.

o A concern was expressed that not enough participants were given the chance to complete it. This experience is very important data to gather. We will look at a process to do a second round of the survey so that we have a opportunity to get a larger sample, and do a staggered analysis.

Home and Community Based Services – Waiver Settings Transition Project Advisory Taskforce Meeting Minutes July 8, 2015 Page 2 of 3

o It was suggested that the state use their database and mail the survey to every individual who is receiving included waivers. Linda will follow up with Darlene to see if the Ombudsman’s office can help. We will meet with Lorene to see what other options we have.

o We will reach out to self advocacy groups to help get the word out and distribute the survey, but there needs to be some way to ensure that only people receiving the specific waivers that are part of this settings rule fill out the survey.

o A request was made to add a question regarding which region the participant is from, so we can better follow up.

Validation Process o Surveyors. We are identifying people now. Some are former agency and/or

Bureau employees. Some Leadership grads. UNH will hire them as independent contractors. Mary will be their direct supervisor, and will assign sites. Surveyors will make appointments prior to going out to sites.

o All sites and participants will be part of the selection pool for validation, regardless of whether they completed a survey.

o Will be using the exact same tool for the validation as was used for the initial survey.

o Mary and Linda will be meeting with people next week to interview and provide training in interview techniques. We want to make sure information is collected that will help in the process while creating a level of comfort in the folks being interviewed, providing an atmosphere that is relaxed and conversational, easing anxiety of any fears or concerns of funding and/or service loss.

o Suggestions from Taskforce for surveyor training: Ensure that surveyors ask questions just as they are written. Give

examples if people ask for them. It will be important for surveyors to be familiar with terminologies Surveyors need to be sensitive to those being interviewed because there

is a sense of fear. Need to communicate that this is a process of gathering information so we can identify steps for reaching compliance.

It was noted that some of the expectations are facility based, some are not (ie. Liability for people going into the kitchen at an assisted living facility)

Under activities it is important to emphasize that it’s when people want to do activities, not when they’re available.

Meals/Snacks is a sensitive topic in CFI settings The surveyors will meet with the providers and then meet with the

participants; they will go back to the provider if clarification is needed.

Home and Community Based Services – Waiver Settings Transition Project Advisory Taskforce Meeting Minutes July 8, 2015 Page 3 of 3

At the end of the visit there will be closure with the provider. It will not be to provide information, rather to let them know the surveyor is finished.

Timelines o All of the validation interviews need to be completed by October 2. o Intention is the conduct 450 site interviews (about 26% of the sites). This will

impact at least 1500 participants. o Interviews with the participants will be coordinated during site visits. o All the data needs to be analyzed and a report written and a draft plan ready for

review by this Advisory Taskforce and DHHS leadership. o Public comment needs to be completed by February 12. o Final report to CMS March 16, 2016.

Other Business o Next Advisory Taskforce Meeting, August 12, 10am-12noon at the IOD in

Concord.


Advisory Taskforce Meeting

August 12, 2015 – 10am to 12 noon


Agenda

Attendance:, Adrienne Mallinson, Ryan Donnelly, Cynthia Gaudreault, John Fenley, John

Richards, Eric Johnson, Darlene Cray, Jennifer Bertrand, Tiffany Barrow (alternate for Heather Hannafin), Deb Fournier, Kaarla Weston, Linda Bimbo, Mike Fitts (guest)

Introductions o Guest: Mike Fitts was introduced. He is one of the 15 validation site surveyors

and attended at the request of the Advisory Task Force.

Review of CMS expectations o The document “CMS Expectations” excerpted from the CMS document

“Statewide Transition Plan Toolkit for Alignment with the HCBS Final Regulation’s Setting Requirements” dated September 5, 2014 was reviewed. Points included:

What is a Statewide Transition Plan (STP)? Who submits? How can states determine alignment with the new Federal requirements

on HCBS settings? What does CMS expect to see in a Statewide Transition Plan?

o Discussion included: NH’s approach to the inventory, assessment, and remediation process

including:

Review of regulations, standards, rules, policies and other requirements to ensure compliance with the Federal requirements.

Assessment process (development of tools, provider self-assessment, participant surveys, validation site visits based on sites of concern and sampling methodology)

Whether the Advisory Task Force will exist or have a role beyond submission of the STP. We will need to wait for the final report and recommendations.

How will the cost of compliance be handled? It will depend on the recommendations in the STP. DHHS will need to plan for it.

Process for identification of those sites that: 1) fully align with the Federal

requirements, 2) Do not comply with the Federal requirements and will

require modifications, 3) Cannot meet the Federal requirements and

require removal from the program and/or the relocation of individuals,

and 4) are presumptively non-HCBS for which the state may provide

justification/evidence to show that those settings do not have the

characteristics of an institution and do have the qualities of home and

community-based settings (to be evaluated by CMS through the

heightened scrutiny process)

Remedial actions in the STP will include a detailed description of the

actions the state will use to assure full compliance with the HCBS settings

requirements, including timelines, milestones and monitoring process.

Review of chart: Steps to Compliance for HCBS Settings Requirements in

a 1915(c) Waiver and 1915(i) SPA.

Eligible sites update o The chart that lists the eligible residential and non-residential sites by rule

number was reviewed. o Discussion included:

87 sites under the CFI Waiver and 363 sites under the DD/ABD Waivers will participate in the validation site visits.

Validation Site Visits o Trained surveyors – 15 individuals, many are Leadership graduates, have been

employed by UNH and trained to conduct the onsite validation surveys. Each visit includes a survey with the provider and a participant.

o Mitt Fitts, one of the trained surveyors, attended as requested by the Advisory Task Force, and shared his experience completing onsite surveys. He acknowledged that providers were very cooperative. He also shared creative ways to accommodate communication with participants, when needed, to collect input.

o Assigned/completed - 159 site visits have been assigned to surveyors and to date

32 have been completed.

Strategy to increase number of participant surveys o Based on Advisory Task Force input strategies to increase the number of

participant surveys was developed including: Conducting at least one participant survey at each onsite visit Working with volunteers from the Ombudsman’s Office to engage

additional participants Expand collection of DD/ABD participant surveys at community

participation sites Remind Service Coordinators and Case Manager of the need to increase

input from participants o Discussion included:

Whether guardian input was required before interviewing participants. Since this is similar to a licensing or certification visit the guardian’s permission has not been required – although some have provided input.

Other Business o The DRC representative shared concern that the list of sites with concerns that

they provided, when asked, was communicated to vendors as a DRC targeted list. It was not clear how that may have happened and Linda will follow up.

o Transportation as a means of independence and access to the community was discussed. In particular the allowance of staff to transport participants. One Advisory Task Force member offered to share his policies and procedures with others to help them adopt this practice.

o Selection of participants during site visits was discussed. It is important that providers not select the participant for the survey. They may ask who is willing to participate and then give the surveyor options. We will follow up with surveyors to let them know. In addition, we have resources if interpreters are needed.

o The Ombudsman’s Office offered to share best practices and other resources on inclusion of person center planning approaches.

Next meeting will be held on September 9, 2015, 10 am – 12 noon at the UNH Institute on Disability.

Home and Community Based Services – Waiver Settings Transition Project Advisory Taskforce Meeting

September 9, 2015 – 10am to 12 noon UNH Institute on Disability, 56 Old Suncook Rd. Suite 2, Concord, NH

Minutes

Present: Linda Bimbo, Sue Orr, Darlene Cray, Mary St. Jacques, Lisa DiMartino, Rosemary Simoneau (NH Healthcare Assoc), Adrienne Mallinson, Ryan Donnelly, Kaarla Weston, Cindy Gaudreault, John Richards, Heather Hannafin, Deb Fournier, John Fenley, Cheryl Steinberg Validation Site Visits:

Chart that identifies the number and types of sites that we are doing validation on was distributed.

We have 17 surveyors conducting on-site validations

The number of Adult Family Services sites has changed because the two of the sites that were originally on the master list are no longer providing those services.

Total of 33 sites assigned to be surveyed for CFI

Total of 296 sites assigned to be surveyed for DD/ABD.

Challenges on the CFI side: Lack of contact information or inaccurate information for the different sites. Contact info for some people who no longer work at that location. There are also a number of CFI sites that do not have email addresses – and it was necessary to look up site info on web to find phone number to contact those sites by phone. ARCH was contacted, and provided some assistance, but still not everyone is a member of that organization. A letter was sent to CFI sites to get contact information. This identifies a glitch in the process of updating contact information for certified sites. The Waiver Transition Team will include this issue in the recommendations for resolution in the report.

Challenges on DD/ABD side: There have been issues with people not being responsive to the email that was sent. Generally this was because the contact was usually the executive director of the organization, who assumed someone else at the agency was responding. In response, the master list was changed to include the contact for certification for each organization. This helped tremendously. Some agencies were still not responding; however, once a conversation was had with them, they have been very responsive. Some agencies are still pushing back and are not responding well.

The surveyors have been doing their very best to contact people, make appointments, and perform validation interviews.

There have also been people who have refused to participate – both individuals and guardians. One participant-directed site has refused to participate. Sometimes it is just an individual who declines, which is their right, and other times an organization (provider) has declined which is a concern. The team is developing a plan of action to

Home and Community Based Services – Waiver Settings Transitions Project Advisory Taskforce Meeting September 9, 2015 Page 2 of 3

determine the best way to address this. Any program that has not cooperated will be added to the additional scrutiny list to be reviewed later.

Additionally, some sites have had a change in status (closed, individual has changed locations, etc.). The master list that is being used was generated in March, so the Team is still working on a list from that date. These changes were made between then and now.

Participant surveys:

Current status: Original round had low numbers. The Team has reached out to some of the Community Participation Services sites, to ask them to support individuals to complete the participant survey. There are a lot of individuals who are served in the CPS settings and the hope is that a large number of those receiving services will complete the survey.

The Team reached out to Darlene Cray at the Long Term Care Ombudsman’s office for help in reaching out to more individuals receiving services through the Choices for Independence (CFI) waiver to complete additional participant surveys.

Some of the language in the survey needed to be simplified, and made more understandable for the participants (acronyms, access to the refrigerator, etc.)

We are currently at a little over 600 entered, with some written ones in house that still need to be entered, and more surveys being done.

Will be using information from the National Core Indicator surveys that have been completed that will help us analyze the Participant Surveys.

Learning opportunities: Understanding of the process of Providers in CFI and DD/ABD are different.

Regulatory review process by DHHS:

Lists of CFI DD/ABD statutes and rules for the waivers were distributed to the group.

These are currently being reviewed, to make preliminary determinations on what changes will need to be made to be in compliance with the new CMS requirements.

Each of the statutes and rules needs to be reviewed individually. Not all of the rules will be touched by the new regulations.

The Team will need to make recommendations as to how these issues will need to be addressed.

Michelle Winchester did the initial review, but the DHHS attorneys will provide the final evaluation report, including suggested tasks and timelines for remediation.

A question was asked about how these new regulations would be disseminated to the people receiving these services. The Bureau would put together documents, hold public sessions requesting comments/questions, etc. JLCAR already has a system in place to introduce new regulations to the public. Additionally, the State-wide Transition Plan will include the suggested changes, and there will be a public hearing/comment period associated with this.

Home and Community Based Services – Waiver Settings Transitions Project Advisory Taskforce Meeting September 9, 2015 Page 3 of 3

Other Business:

Kaarla attended the Home and Community Based Conference in Washington DC.

1250 participants

They offered HCBS Settings Rule guidance sessions at which Kaarla learned that the information we have here in NH is in line with what she learned in these courses.

They did not identify NH by state, but used our regional design system as the best model for service design.

She spoke with folks from ND, which was the first state to be approached by CMS regarding the funding design. The shared a story about a home on the same site location of an institution. Four people, who were all formerly residents of the institution, lived and co-owned that home. ND was concerned that they were vulnerable, and asked CMS to come and review them; and CMS determined that this was a self-driven model, and they were not vulnerable.

CMS also dropped by a Day Service while they were there. They determined that the folks were not getting out into the community as often as they should, and therefore determined that they were not considered to be Home and Community based.

Next Meeting: Wednesday, October 14, 2014, 10am – 12noon NH Council on Developmental Disabilities 2 ½ Beacon Street, Suite 10 Concord, NH

Home and Community Based Services – Waiver Settings Transition Project Advisory Taskforce Meeting

LOCATION: Council on Developmental Disabilities, 2 ½ Beacon St., Suite 10 Concord

October 14, 2015 – 10am to 12 noon Minutes

Introductions: Jen Bertrand, Ryan Donnelly, Cynthia Gaudreault, David Ouellette, John

Richards, Rosemary Simineau, Andrienne Mallison, Heather Hannafin, Kaarla Weston, Linda Bimbo, Mary St Jacques, John Fenley, Cheryl Steinberg.

Validation Site Visits Provider Site Visits.

o Validation team has worked hard to complete the required validation visits. Deadline for completing visits and entering data was Friday 10/9/15 at midnight. Total of 472 site visits were completed.

*

o o o o

* not mutually exclusive

o More detail is currently being gathered on the sites and this will be shared at future meetings. DHHS is pleased with the number of sites visited. However, some providers refused to participate in this process. Some organizations felt that it wasn’t appropriate for them to participate. Education was helpful for this. If someone refused, we made a note of it and moved on to an alternate site. Refusals were sporadic with no pattern. Bureau will be following up with sites that have refused, with the potential of conducting visits to ensure safety of the people at that site.

o There was some clarification needed regarding addresses and contact information. A meeting was held with DHHS Licensing and Certification staff and additional information was provided. The Bureau is aware of the situation, and they are following up on those sites. Some of the issues are because of changes that occurred since the master list that we are working with was established.

WAIVER TYPE OF

SETTING

TOTAL #

OF SITES

# OF SITES VISITED

ABD/DD NON-RES 913 164*

RES 1,069 254*

CFI NON-RES 13 13

RES 76 42

TOTAL 2,071 472

Home and Community Based Services – Waiver Settings Transition Project Advisory Taskforce Meeting October 14, 2015 Minutes Page 2 of 4

o Feedback from validation team members has been useful – feeling that it has been a positive experience. The validation team will have a debriefing luncheon where stories will be shared. A request was made to put some of these stories into a report to share with the group.

Participant Site Visit Surveys

o 399 participant surveys were completed during the validation process. Totals will be part of the final report. We are listening to people and most were happy to share their experiences. Understanding the complaint process is a systemic issue; some participants understood while others need additional information and support. Feedback from team members has been very positive – we have changed people’s lives – in some cases, we’ve seen immediate change. In one case, the provider was able to learn of a way the individual communicated their approval, and in another situation the team member was able to provide a resource for a provider to help the individual. Participant refusals rarely happened. Some individuals would get through part of the survey and then say they were done, which was respected. This was reflected in the data we collected.

Additional Input o AAIDD Forum (American Association on Intellectual and Developmental

Disabilities). Linda and Mary attended this meeting - all of Region 10 (NH is part of region 10). This meeting was to review the HCBS Settings Rule by HSRI and included a review of Transition plans submitted by each of the states. Highlights from each state were reviewed. NH was acknowledged for the fact that we got a lot of feedback during the public comment period, and that we listened and responded to that feedback. Particularly noted was our expansion of the representation of the Advisory Taskforce. We were also acknowledged for our Taskforce – that we meet regularly, that we share and listen to ideas, and that we respond to the input from the members of this Taskforce. We were also recognized for the fact that the Taskforce is an active group, that we post minutes, and the comments are being implemented into our process.

o ACL Webinar (Administration for Community Living) is a partner with CMS around the settings rule. They have been conducting regular webinars to discuss best practices, etc. NH is in about the same place as other states with regard to where we are in the process (currently working on developing the plan). Their expectation is that states are aware of 100% of the sites and where they are in the compliance process. The survey process is a vehicle to help develop the final


plan. We will look at all the difference processes (certification, licensing, etc.) that will ensure that all sites are in compliance (or working toward compliance), when they sign the contracts. Within a 2-year time, 100% of the sites go through a licensing/certification process, so all of the sites will be seen. Second issue, during the webinar they mentioned a number of best practices, e.g., crosswalk between mandatory provider self-assessment, validation visit, and participant survey. We didn’t approach this in the initial plan, but we can address this in our plan. We are not required to measure compliance with the HCBS Rules for people who live in their own home or in a family home through the In-Home Supports Waiver (many CFI waiver participants fall under this as well); however, the state is responsible to make sure these individuals are not isolated. Individuals who are living in a setting that is not in compliance, would they have a right to a hearing if losing their supports were at risk – yes. Even if they won, however, Medicaid will not pay for a setting that is not in compliance.

Steps to compliance for HCBS Settings Requirements in a 1915(c) Waiver Statewide Transition Plan (STP). Our responsibility is to report to CMS with a statewide plan. Each state has to report three different categories: Yes, Not Yet, and No. Based on the data, the “Yes” category may be none or a very small number. Majority of our sites will be in the “Not Yet” category. There is a lot of opportunity to improve and make changes. We will identify how as many sites can come into compliance. We will have to report on the entire list of No’s”. We don’t know of any who cannot, but we know of some sites that will not. These sites do not (or will not) accept Medicaid (mostly CFI). We could include this information as a trend analysis in the STP. We need to identify sites who are receiving CFI funding and are considered institutional settings, for the “No” list. We are working on this now.

Review of CMS letter. A copy of the letter was shared and reviewed. o CMS is responding to every state based on their first submission. They agreed

that there is enough time to come into compliance. o Covered settings (residential/non-residential) will be detailed in our STP. They

asked that we talk about the assessment process in great detail, including the regulatory process and specific aspect of each regulation (compliant, non-compliant, and silent). DHHS attorneys are continuing to meet to do the regulation review and report their findings, with a specific timeline.

o CMS asked questions about transition framework team, as well as wanting more information about our Advisory Taskforce Team. CMS wants to make sure we have information about the content of the group, and that it’s free of conflict of interest. We feel very confident about this.


o CMS has requested that we need to come up with a plan to address sites that refused to complete the self-assessment.

o CMS and ACL will not tell states how to complete tasks, but will provide guidance on this. We will need to describe our oversight and monitoring process in the STP.

o CMS has asked for information and training to be provided to sites to assist sites to come into compliance. We believe this will be a strength of our STP.

o Remedial actions will be a work plan including anything we need to do to come into compliance.

o We did not reference relocation of beneficiaries in our Transition Framework and will need to develop a process.

o We need to look at people who fall into the “No’s,” the state of NH will need to decide how to handle this, through policies that will be reflected in the STP. We don’t know yet how this will be played out.

o Heightened Scrutiny – this may be considered for settings that are presumed to be institutional. (Site is located in the same building where, on the grounds of or immediately adjacent to in-patient care or treatment is provided). We also have the address the effect of isolating. The state must be the entity that requests heightened scrutiny.

November 11 meeting rescheduled to November 10, 10am – 12noon at DD Council offices due to Holiday

Home and Community Based Services – Waiver Settings Transition Project November 10, 2015 – 10am to 12 noon

Minutes Introductions:

o Linda Bimbo, Heather Hannafin, Rosemary Simineau, Adrienne Mallinson, Cindy Gaudrealt, Kaarla Weston, Deb Fournier, Mary St. Jacques, John Richards, Lisa DiMartino, John Fenley, Jeff Dickinson, Jennifer Bertrand

Validation Site Visits - Completed o A chart of the eligible sites that were used as our master list at the beginning of

the process (pulled March 30, 2015) was distributed to the group and reviewed. These numbers are always changing because of various reasons, including new providers, individuals moving or passing way, people moving into new facilities, etc. These numbers will be reflected in the Statewide Transition Report that is submitted to CMS.

o Total of 89 CFI Waiver sites are eligible for this process: 13 Adult Day, 3 Adult Family Care Residences, and 73 Residential Care.

o Total of 1982 ABD/DD eligible sites: 1044 Community Residences, 3 Residential/Treatment Rehab Centers, 22 Community Residence (4 or more), 63 Day Services, 770 PDMS, and 80 Personal Care Services (with day service component).

o ABD/DD (non-residential) we visited 164 out of 913 sites. While there are pockets of excellence, none of these are fully in compliance yet.

o He-M 524 is not included in this scope, but there are other means where these family homes will be reviewed. (Service agreements get reviewed annually)

o Some sites cannot be determined to be in compliance due to their location – on the grounds of an institution. These sites may be recommended by the State for heightened scrutiny. The State must request heightened scrutiny. The team has compiled a list and provided that to the Department, who will review. These sites were compiled by location, not by vendor.

o There will be a toolkit developed to assist providers to come into compliance. This group will be an ongoing participant in this process. There are resources on both sides (CFI and DD/ABD) that can be used to help develop processes for all settings in order to help come into compliance. The State will also be available to assist sites to determine what will be needed at each site.

NH flow chart o A chart was distributed which illustrates the State of NH’s process. (see below) o Process for full compliance will be addressed in the Statewide Transition Plan.

Some sites will need to adjust their practices in order to come into compliance. Individual sites will need to look at their present practices based on the new CMS guidelines. We will have ongoing monitoring through a number of sources

Home and Community Based Services – Waiver Settings Transition Project November 10, 2015 Minutes Page 2 of 3

including, certification and licensing processes, quality networks, employment groups, etc.

o There have been ongoing meetings between the Transition Team and Licensing/Certification staff at the Department. The regulations will be changed or adjusted in order to include all the new CMS proposed changes.

o CMS breaks down the regulations by categories. The Plan will be broken down in the same way. It will address each topic individually and include the resolution plan, as well as the State’s ongoing monitoring plan.

STP format and timelines. Linda and Mary are currently drafting the language for the first draft of the Statewide Transition Plan. CMS provided a basic element review tool (available on their website), which we are using that as a guideline when we compile our report. The first draft of this report will be provided to the Taskforce for review at the next meeting (December 9). The goal is to have a final draft completed by January 15, 2016. The deadline to submit the plan to CMS is March 31, 2016. It will be at least 100 pages long.

o We will prepare a person-friendly, shortened version of the plan in order to present to organizations to ensure that we get feedback from as many diverse groups as possible. The report will be made widely available via websites (state, DRC, etc.), as well as written copies.

There will be a 30-day public comment period after the Statewide Transition Plan is completed and disseminated. The STP is very prescriptive and specific. However, the Public are not restricted regarding what they can comment on. The Public can make any comments on any topic – including funding, etc. The State is required to respond to every comments – Adopted it or we did not adopt it, and here is why. All the comments and responses get submitted to CMS, who will review and respond.

Next Meeting: December 9, 2015, 10am – 12pm, at IOD, Concord

2014 CMS creates new expectations for HCBS settings.

March 2015

NH creates Plan to Plan;

Submits to CMS

October 2015

CMS gives feedback on

Plan to Plan

Due March 2016 NH creates WTP

Using data collected, identifies sites o In compliance o Not yet in compliance o Those presumed institutional

Develops Work Plan to get sites in compliance over next 3 years o Includes steps for achieving compliance o Includes steps for monitoring ongoing compliance

WTP Reviewed by CMS

CMS gives feedback to NH

WTP Revised based on

CMS feedback

Revised WTP submitted

to CMS

Plan Implemented

June 2018

Status update completed

on all sites

NH monitoring to ensure ongoing compliance

NH develops plan for site:

Relocation of beneficiaries

Other steps

March 2015 NH implements action steps

Self-Assessments

Surveys

On-Site Visits

Plan Implemented March

2019 All HCBS Settings

In Compliance

Approved Not Approved

Site in compliance Site not in compliance

1


Advisory Taskforce Meeting

December 9, 2015 – 10am to 12 noon

Minutes

1. Review of Draft Statewide Transition Plan – the draft STP was sent to all ATF members which included a summary of the assessment data. The agenda was to focus on discussing and developing goals and remediation steps. Comments included:

o Section II – Overview of HCBS Waivers in NH: under the DD/ABD waiver descriptions related to He-M 525, He-M 521, and under the CFI waiver He-P 818, He-P 813, He-P 804 and He-P 805, all areas considered in compliance since the services are home-based, we need to add a reference and process for ensuring these sites are not isolating.

o Section III, A. 3. Review of Existing Processes: Comments included a fuller description of the Ombudsman’s Office role, the addition of NH Legal Assistance and Brain Injury Association, and additional information about People First and their role as a self-advocacy group in NH.

o Section III, B. DD/ABD Settings, a. participation in activities: Remediation recommendations/discussion – needs to include training, education, quality of activities, include what it means to be a quality activity (list) in the tool kit, engage with community resources (i.e. libraries), focus on the person and what they want first – not just activity for the sake of activity, train people to ask the right questions, find ways to encourage people to do things that they don’t think/know they can do or outside their comfort zone.

o Section III, B. DD/ABD Settings, c. community employment: Remediation recommendations/discussion - dive deeper in jobs offered and wanted, BDS committed to goals in this area, providers need to better define opportunities, all about consumer choice.

o Section III, B. CFI Settings: Remediation recommendations/discussion – Need to integrate infrastructure and support for DD/ABD systems, strengths, and opportunities with CFI settings/services. Under Area Agency system?? Share the wealth. Use systems in DD/ABD world to strengthen CFI world. Funding for services needs to be included in report. CFI assisted living rate is $49/day = $17,885/year. How to we include role of CFI case manager more like DD/ABD service coordinator? Review medical model for assisted living – need model more like DD/ABD to support needs other than ADLs. Transportation – need to improve in order to access community activities. Eligibility for nursing home level of care – does that lead to assisted living models that focus on ADL and medical care vs. access to community and person centeredness. Possibly use Area Agency Human Rights Committees to review plans for people in Assisted Living settings.

2

Addresses individual plan issues for safety. CFI representative raised concern about adding significant additional expectations without additional funding. Small settings will close with residents ending up in nursing home (unintended consequence).

The Waiver Transition Team will develop goals and remediation steps and timelines for the DD/ABD and CFI waivers for inclusion in the draft STP. ATF members can submit written comments to WTT.

2. Timelines and communications

The following are draft timelines for submission of the STP to CMS: 12/18/15 – final draft to DHHS 1/6/16 – final draft approved by DHHS 1/13/16 – review draft with Advisory Task Force 1/18 – 2/19/16 – public comment period (33 days) 2/21-3/25/16 – respond to public comments and finalize plan 3/31/16 – submit plan to CMS

3. Next meeting: January 13, 2016 - IOD

home and community based settings transition … and community based settings transition project ......

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